Available literature indicates pre-eclampsia is a public health concern. Pre-eclampsia is a leading cause of maternal-related mortality. Available evidence recommends patient education to address risk factors. Thus, this quality improvement (QI) aims to improve blood pressure in women with a history of pre-eclampsia during their pregnancy. This paper presents a thorough synthesis of the literature that addresses the problem and practice gap. The assignment also presents a section on the selected intervention to enhance blood pressure among postpartum women with a history of pre-eclampsia during their pregnancy. Five major themes were identified including pre-eclampsia risk factors, complications associated with pre-eclampsia, management of postpartum preeclampsia, and lifestyle-based patient education.
Online pre-eclampsia Diseases Prevention Program as QI
This QI project proposes the implementation of an online pre-eclampsia diseases prevention program to improve blood pressure in women with a history of pre-eclampsia during their pregnancy. The online pre-eclampsia disease prevention program differs from the research study since it will be data-driven as opposed to a research project which is question-driven. Al-Surimi (2018) emphasized that QI projects are data-driven and are interested in demonstrating improvement of specific outcomes. For instance, the current project aims to use pre-and post-test data to determine if an online pre-eclampsia disease prevention program compared to current practice improves blood pressure reading of women with previous pre-eclamptic complicated pregnancies. Another significant difference between QI and research is that research is designed to contribute to generalizable knowledge while QI is designed to implement knowledge, evaluate a program or process as per the established standards within a specific setting. Hence, unlike research, this QI is designed to evaluate the efficacy of an intervention and does not aim to produce generalizable knowledge outside the practice site. Research tends to follow a rigid protocol that remains unchanged throughout, while QI follows an adaptive or iterative design (Backhouse & Ogunlayi, 2020). The QI project will use the iterative cycle, such as Plan-Do-Study-Act (PDSA), to implement and assess changes.
Preeclampsia Risk Factors
Past studies indicate that identifying preeclampsia risk factors helps inform evidence-based intervention (Bibbins-Domingo et al., 2017; Henderson et al., 2017). Hypertensive disorders during pregnancy affect about 10% of pregnancies globally, including 3-5% of all pregnancies complicated by preeclampsia (Fox et al., 2019). In 2017, the United States Preventive Services Task Force (USPSTF) updated screening recommendations for risk factors including multifetal gestation, renal disease, history of preeclampsia, diabetes, chronic, and chronic hypertension (Bibbins-Domingo et al., 2017; Henderson et al., 2017). Chronic and pre-existing hypertension is considered a significant risk factor for preeclampsia, complicating between 1% and 5% of pregnancies (Bibbins-Domingo et al., 2017). Nevertheless, identification of risk factors can cause anxiety among women, especially those pregnant. Nonetheless, Henderson et al. (2017) noted that identifying women at considerably higher risk for preeclampsia based on medical history and routine examinations may inform risk-based intervention. Rana et al. (2019) stressed that enhanced risk stratification may help lower incidences of preeclampsia among high-risk women.
The increasing of cases of pre-eclampsia necessitates the identification of risk factors to inform evidence-based interventions. Fox et al. (2019) classified women at high risk of preeclampsia if they had a history of hypertensive disease during a previous pregnancy or maternal autoimmune diseases, chronic kidney disease. The authors also classified women at moderate risk for preeclampsia if they are 40 years and older, have body mass index (BMI) ≥35kg/m, a pregnancy interval of over 10 years, family history of preeclampsia, and multifoetal pregnancy. Nonetheless, Fox et al. (2019) noted that despite the prevalence of preeclampsia, the risk factors identified lack accuracy in preventive therapies. As such, the existing preventive therapies only reduce the risk of preeclampsia moderately. Although the existing assessment of risk factors lack accuracy, presence or identification of high-risk factors is deployed to guide effective evidence-based prevention to reduce the risk of pre-eclampsia if administered promptly. Complications Associated with Pre-eclampsia
Preeclampsia is the second leading cause of maternal mortality across the world and might cause serious complications. Pre-eclampsia affects about 4% of all pregnancies across the United States (Bibbins-Domingo et al., 2017). Pre-eclampsia is linked to severe complications, including stroke and organ failure (Bibbins-Domingo et al., 2017). Recent findings revealed that women with pre-eclampsia during pregnancy are associated with 10-year cardiovascular (CVD) risk. There is an increasing trend that the history of pre-eclampsia needs to be considered in CVD risk stratification. Higher risk of future CVD among women who had experienced pre-eclampsia during pregnancy increases risk of chronic hypertension by 3.7 fold, risk of heart failure by 4.2% fold, risk of stroke by 81%, and two-fold risk of atrial arrhythmias and coronary disease (Coutinho et al., 2018). However, whether these complications are associated with pre-eclampsia, the association is challenging to distinguish (Coutinho et al., 2018). Though it is challenging to discern the association between pre-eclampsia and some of these complications, identifying them helps show the magnitude of the problem.
Severe pre-eclampsia is associated with significant adverse outcomes. Some common complications linked to severe pre-eclampsia include hemolysis, elevated liver enzymes, and low platelet syndrome (Ngwenya, 2017). Although the mortality of pre-eclampsia has reduced considerably in the United States due to increased antenatal surveillance coupled with early interventions, the postpartum and long-term complications of pre-eclampsia continue to rise in significance and number (Coutinho et al., 2018; Rana et al., 2019). Nonetheless, delivery might resolve some of these complications. Although some of these complications may be resolved after delivery, Rana et al. (2019) noted that preeclampsia could persist, and some cases can develop to severe complications.
Management of Postpartum Pre-eclampsia
There are various management measures of postpartum preeclampsia. Current management of pre-eclampsia includes perinatal blood pressure control and monitoring, prenatal aspirin-based therapy amongst high-risk women, and follow-up of postpartum blood pressure (Rana et al., 2019). In addition, researchers recommend postnatal services for women with a history of pre-eclampsia. There is a need to raise awareness of risk factors. This can be achieved through patient education. Nurses offer most postpartum discharge instructions to patients. Thus, they must offer high-quality and clear information to patients covering relevant points to modify risk factors to reduce mortality and morbidity associated with pre-eclampsia (Suplee et al., 2016).
Extant literature further shows that postpartum pre-eclampsia can be managed using medications. A randomized controlled trial (RCT) by Veena et al. (2017) found that Furosemide effectively in postpartum management of severe pre-eclampsia. Nevertheless, Ngene and Moodley (2020) revealed that the more the number of antihypertensive drugs prescribed, the higher the blood pressure and challenging to control in that patient. The authors concluded that initiation of antihypertensive drug therapy and healthcare facility contact dose no always yield improved blood pressure readings. Nonetheless, Veena et al. (2017) indicated that the use of a short course of nifedipine together with furosemide considerably reduces the need for antihypertensive among severe preeclampsia women during postpartum. Ngene and Moodley (2020) recommended that due to strong evidence that women with pre-eclampsia have the likelihood of developing complications, there is a need for follow-up interventions. Though great strides have been made in managing postpartum pre-eclampsia, the disease remains among the leading cause of death of pregnant women (Ngene & Moodley, 2020). Thus, effective and timely prevention is needed to address some of the complications associated with postpartum among women with a history of pre-eclampsia.
Lifestyle-Based Patient Education
Enhanced approaches to educate patients with a history of pre-eclampsia are required to inform risk-based prevention. There is substantial evidence that online pre-eclampsia patient education targeting lifestyle modification is an effective intervention in improving blood pressure in patients. It is reported that patient education on diet and lifestyle could help lower risks associated with pre-eclampsia (Giannakoum et al., 2017; Skurnik et al., 2016). The results highlighted the significance of patient education concerning lifestyle modifications and diet to improve blood pressure. In addition, available guidelines recommend that pregnancy complicated by pre-eclampsia be followed by lifestyle changes, including physical activity and intake of a healthy diet to prevent complications, such as CVD later (Giannakoum et al., 2017). The findings serve as an indication that patient education on lifestyle modifications in postpartum hold enormous potential in improving blood pressure. Nevertheless, Skurnik et al. (2016) indicated that patients were unaware of the link between pre-eclampsia and complications, such as CVD. Skurnik et al. (2016) recommended improvements to patient-provider communication and online tracking of blood pressures to achieve lifestyle modifications.
Available evidence has shown that online education on lifestyle changes is effective among women with a history of pre-eclampsia. A systematic review of RCTs by Lui, Jeyaram, and Henry (2019) revealed that online-based lifestyle coaching in women who had a pregnancy affected by pre-eclampsia promoted healthy diet intake and increased physical activities with a potential to lower their blood pressure. Similarly, Maric-Bilkan et al. (2019) reported that patient education on lifestyle modifications could reduce complications linked to pre-eclampsia. Thus, an online pre-eclampsia prevention program that emphasizes lifestyle changes may improve patients’ blood pressure.
Counterargument/Alternative Perspectives
Though online lifestyle-based patient education has been shown to be effective and cost-effective in addressing pre-eclampsia risks in postpartum, there exists contradicting evidence. For example, Maric-Bilkan et al. (2019) cautioned that although lifestyle-based patient education can prevent pre-eclampsia, more implementation of the evidence-based intervention is needed to demonstrate the efficacy of this form of intervention in enhancing patients’ blood pressure. Similarly, in their study, Suplee et al. (2016) revealed that patient education might be insufficient since patients are unlikely to receive evidence-based information during discharge and follow-up, worsening their conditions, which shows a practice gap. Nonetheless, Rana et al. (2019) stressed that nurses could be better positioned to teach women how to recognize and address risk factors by improving postpartum education. This demonstrates that increased postpartum education concerning risks for post-birth complications could be helpful.
References
Al-Surimi, K. (2018). Research versus quality improvement in healthcare. Global Journal on Quality and Safety in Healthcare, 1 (2), 25–27. https://doi.org/10.4103/JQSH.JQSH_16_18
Backhouse, A., & Ogunlayi, F. (2020). Quality improvement into practice. BMJ, 1(1), 368– 374. https://dx.doi.org/10.1136%2Fbmj.m865
Bibbins-Domingo, K., Grossman, D. C., Curry, S. J., Barry, M. J., Davidson, K. W., Doubeni, C. A., & US Preventive Services Task Force. (2017). Screening for preeclampsia: US preventive services task force recommendation statement. JAMA, 317(16), 1661-1667. https://jamanetwork.com/journals/jama/article-abstract/2620095
Coutinho, T., Lamai, O., & Nerenberg, K. (2018). Hypertensive disorders of pregnancy and cardiovascular diseases: Current knowledge and future directions. Current Treatment Options in Cardiovascular Medicine, 20(7), 1-11. https://link.springer.com/article/10.1007/s11936-018-0653-8
Fox, R., Kitt, J., Leeson, P., Aye, C. Y., & Lewandowski, A. J. (2019). Preeclampsia: Risk factors, diagnosis, management, and the cardiovascular impact on the offspring. Journal of clinical medicine, 8(10), 1625-1647. https://doi.org/10.3390/jcm8101625
Giannakoum, K., Yiallouros, P., Evangelou, E., & Papatheodorou, S. (2017). Interventions for preeclampsia prevention: An umbrella review of meta-analyses of randomized trials. European Journal of Public Health, 27(3),93-94. https://doi.org/10.1093/eurpub/ckx187.237
Henderson, J. T., Thompson, J. H., Burda, B. U., & Cantor, A. (2017). Preeclampsia screening: evidence report and systematic review for the US Preventive Services Task Force. JAMA, 317(16), 1668-1683. https://jamanetwork.com/journals/jama/article-abstract/2620094
Lui, N. A., Jeyaram, G., & Henry, A. (2019). Postpartum interventions to reduce long-term cardiovascular disease risk in women after hypertensive disorders of pregnancy: A systematic review. Frontiers in Cardiovascular Medicine, 6, 160-175. https://doi.org/10.3389/fcvm.2019.00160
Maric-Bilkan, C., Abrahams, V. M., Arteaga, S. S., Bourjeily, G., Conrad, K. P., Catov, J. M., Costantine, M. M., Cox, B., Garovic, V., George, E. M., Gernand, A. D., Jeyabalan, A., Karumanchi, S. A., Laposky, A. D., Miodovnik, M., Mitchell, M., Pemberton, V. L., Reddy, U. M., Santillan, M. K., Tsigas, E., Thornburg, K. L. R.,…& Roberts, J. M. (2019). Research recommendations from the National Institutes of Health workshop on predicting, preventing, and treating preeclampsia. Hypertension, 73(4), 757-766. https://doi.org/10.1161/hypertensionaha.118.11644
Ngene, N. C., & Moodley, J. (2020). Pre-eclampsia with severe features: Management of antihypertensive therapy in the postpartum period. The Pan African Medical Journal, 36. 1-15. https://doi.org/10.11604/pamj.2020.36.216.19895
Ngwenya, S. (2017). Severe preeclampsia and eclampsia: Incidence, complications, and perinatal outcomes at a low-resource setting, Mpilo Central Hospital, Bulawayo, Zimbabwe. International Journal of Women’s Health, 9, 353-357. https://doi.org/10.2147/IJWH.S131934
Rana, S., Lemoine, E., Granger, J. P., & Karumanchi, S. A. (2019). Preeclampsia: Pathophysiology, challenges, and perspectives. Circulation Research, 124(7), 1094-1112. https://doi.org/10.1161/CIRCRESAHA.118.313276
Skurnik, G., Roche, A. T., Stuart, J. J., Rich-Edwards, J., Tsigas, E., Levkoff, S. E., & Seely, E. W. (2016). Improving the postpartum care of women with a recent history of preeclampsia: A focus group study. Hypertension in Pregnancy, 35(3), 371-381. https://dx.doi.org/10.3109%2F10641955.2016.1154967
Suplee, P. D., Kleppel, L., Santa-Donato, A., & Bingham, D. (2016). Improving postpartum education about warning signs of maternal morbidity and mortality. Nursing for Women’s Health, 20(6), 552-567. https://doi.org/10.1016/j.nwh.2016.10.009
Veena, P., Perivela, L., & Raghavan, S. S. (2017). Furosemide in postpartum management of severe preeclampsia: A randomized controlled trial. Hypertension in Pregnancy, 36(1), 84-89. https://doi.org/10.1080/10641955.2016.1239735